Form Ct-W4 - Employee'S Withholding Certificate
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1
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4Department of Revenue Services
Form CT-W4
Effective January 1, 2008
State of Connecticut
Employee’s Withholding Certificate
(Rev. 11/07)
Complete this form in blue or black ink only.
Complete this form so your employer can withhold the correct amount of Connecticut income tax from your wages. See Employee Instructions, Page 2.
Step 1 - Determine your Withholding Code:
Select the filing status you expect to report on your federal income tax return. Choose
the statement that best describes your gross income, (see Gross Income, Page 2) and enter the Withholding Code in Step 2, Line 1. See Armed
Forces Personnel and Veterans; or Certain Married or Civil Union Individuals, Page 2.
Withholding
Withholding
Married or Civil Union Filing Jointly
Married or Civil Union Filing Separately
Code
Code
Our expected combined annual gross income is less than or
My expected annual gross income is less than or equal to
equal to $24,000 and no withholding is necessary.
E
$12,000 and no withholding is necessary.
E
Our expected combined annual gross income is greater
My expected annual gross income is greater than $12,000.
A
than $24,000 and less than or equal to $100,500. See Special
I have significant nonwage income and wish to avoid having
Rules for Certain Married or Civil Union Individuals, Page 2.
A
too little tax withheld.
D
My spouse is not employed and our expected combined
I am a nonresident of Connecticut with substantial other income.
D
annual gross income is greater than $24,000.
C
My spouse is employed and our expected combined
Withholding
Single
Code
annual gross income is greater than $100,500.
D
My expected annual gross income is less than or equal to
I have significant nonwage income and wish to avoid having
$13,000 and no withholding is necessary.
E
too little tax withheld.
D
My expected annual gross income is greater than $13,000.
F
I am a nonresident of Connecticut with substantial other income.
D
I have significant nonwage income and wish to avoid having
too little tax withheld.
D
Withholding
Qualifying Widow(er) With Dependent Child
Code
I am a nonresident of Connecticut with substantial other income.
D
My expected combined annual gross income is less than or
equal to $24,000 and no withholding is necessary.
E
Withholding
Head of Household
Code
My expected combined annual gross income is greater
My expected annual gross income is less than or equal to
than $24,000 and less than or equal to $100,500.
A
$19,000 and no withholding is necessary.
E
I have significant nonwage income and wish to avoid having
My expected annual gross income is greater than $19,000.
B
too little tax withheld.
D
I have significant nonwage income and wish to avoid having
I am a nonresident of Connecticut with substantial other income.
D
too little tax withheld.
D
I am a nonresident of Connecticut with substantial other income.
D
Step 2 - Complete Lines 1 through 11:
Sign, make a copy for yourself, and return the original to your employer.
RESET FORM
1. Withholding Code. Enter Withholding Code letter chosen from Step 1 above.
1.
.00
2. Additional withholding amount per pay period: if any, see instructions on Page 3.
2.
.00
3. Reduced withholding amount per pay period: if any, see instructions on Page 3.
3.
4. First Name
Ml
Last Name
5. Home Address
6. Social Security Number
7. City/Town
8. State
9. ZIP Code
Declaration:
I declare under penalty of law that I have examined this certificate and, to the best of my knowledge and belief, it is true, complete, and correct.
I understand the penalty for reporting false information is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
10. Employee’s Signature
11. Date
X
M
M
D
D
Y
Y
Employers Must Complete Items 12 through 20.
12. Is this a new or rehired employee?
No
Ye s
(Enter the date of hire at right.)
M
M
D
D
Y
Y
13. Employer’s Business Name
14. Employer’s Business Address
15. Federal Employer Identification Number
16. City/Town
17. State
18. ZIP Code
19. Contact Person
20. Telephone Number
Employer Instructions on Reverse
1 of 4
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